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Federally Regulated Health Plans & Massage Therapy Coverage

15 Nov 2020 11:54 AM | Carl Wilson (Administrator)

Federally Regulated Health Plans and Massage Therapy

by Dagmar Growe, LMT

There is a lot of confusion surrounding federally regulated health plans. The Every-Category-of-Provider statute requires that insurers must not exclude any category of providers licensed by the state of Washington who provide health care services or care within the scope of their practice for services covered as essential health benefits (WAC 284-170-270). Since this is a state statute it does not apply to anything which is regulated by federal law. This means that massage therapy benefits can either be excluded by any of those plans, or be limited by any number of arbitrary rules the plan chooses. Because the customer service representatives are generally not very forthcoming with information, it is easy to end up with unpaid claims.

This article aims to shed some light on the different types of federally regulated plans and what to be aware of.

  1. Federal Employee Health Plans (i.e. US Postal Workers Health Plan): These never cover massage therapy. However, I have been told otherwise by a customer representative, just to be told later “only if performed by a PT”.

  2. Self-Insured Plans: Large employers or associations like trade unions may opt to create a trust fund for health care expenses, rather than to buy coverage from an insurance company. However, they may then hire an insurance company to administer the trust fund. The best known example of this is Uniform Medical, which is a self-insured plan for WA State employees that is administered by Regence Blue Cross. These plans are regulated by ERISA (Employee Retirement Income Security Act of 1974, a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans). These plans may opt to provide massage therapy benefits, likely because of customer demand, but then apply additional rules which are generally not volunteered by customer service representatives. Here are some examples: “Yes, we cover massage therapy, but only if performed by a PT; but only if billed through a chiropractor, PT or MD office; but only if part of a PT treatment plan and the PT has to bill first”. Additionally, these plans may offer ridiculously low reimbursement rates, and in one case I saw only cover “up to 2 units”. 

  3. Federal Health care plans like Medicare, VA healthcare, and Tricare: These plans never cover massage therapy. However, many Medicare insured people have supplemental plans that will cover massage. It is standard practice for supplemental plans to require a medicare denial before covering remaining expenses. The large insurance companies generally know that massage therapy is never covered, and that massage therapists are unable to obtain a denial, and do not ask for this. Some insurances (or some of their staff) do not understand this, and insist on the denial. In this case filing a complaint with the Office of the Insurance Commissioner will be helpful.

Delegating the research regarding plans to patients will not work, as it is important to ask the right questions. It may be helpful to ask if patients have had massage covered by insurance before, but it will not be a guarantee that a claim will be paid.

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